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helpful website that may help others. This website has practice exams for various nursing classes as well as videos, presentations, notes, nclex help, and many other tools that already are helping me. Hope they help

9 Atherosclerosis is a progressive disease involving the development of arterial wall lesions. As they grow, these lesions may narrow or occlude the arterial lumen. Complex lesions may also become unstable and rupture, leading to acute coronary events, such as unstable angina, myocardial infarction, and stroke. Pepine CJ. The effects of angiotensin-converting enzyme inhibition on endothelial dysfunction: potential role in myocardial ischemia. Am J Cardiol . 1998; 82(suppl 10A):244-275.

11 The HOPE (Heart Outcomes Prevention Evaluation) study was a double-blind, randomized multinational clinical trial. Patients, 55 years or older, at high risk of cardiovascular events (history of either coronary artery disease, stroke, or peripheral vascular disease, or of diabetes and at least one additional cardiovascular disease risk factor) were recruited from 267 centers in 19 countries. Exclusion criteria included heart failure, known low ejection fraction (&lt;0.40), uncontrolled hypertension or overt nephropathy, myocardial infarction or stroke within 4 weeks of study entry, and current use of an angiotensin-converting enzyme inhibitor or vitamin E. Of the 10,576 patients entering the run-in phase, 9,541 were eligible for randomization to treatment. A small subset (244 patients) were randomized to treatment with ALTACE 2.5 mg, given once daily. The remaining 9,297 patients were randomized to treatment with once daily ALTACE (4,645) or placebo (4,652). All patients randomized to the main treatment group (ALTACE) or placebo were included in the main study analyses. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med. 2000; 342:145-153.

13 The primary endpoint in the HOPE (Heart Outcomes Prevention Evaluation) study was a composite outcome that included myocardial infarction, stroke, or death from cardiovascular causes. This landmark trial was halted early, after an average treatment duration of 4.5 years, due to the highly significant risk reductions seen with ALTACE for the primary endpoint. Of the 4,645 patients randomized to ALTACE, 651 (14%) reached the primary endpoint; 826 (17.8%) of the 4,652 randomized to placebo reached the primary endpoint. The relative risk of reaching the composite endpoint in the ALTACE group as compared to the placebo group was 0.78 (95% confidence interval, 0.70 to 0.86) (P=0.0001), a 22% reduction. The reduction in risk was evident in the ALTACE group at the end of 1 year: 169 patients and 198 patients in the ALTACE and placebo groups, respectively, reached the endpoint (relative risk: 0.85; 95% confidence interval, 0.70 to 1.05), a 15% reduction. Package Insert, Altace Prescribing Information as of September 2000

14 Each of the outcomes in the primary composite outcome was analyzed separately. A number of secondary outcomes, including all-cause mortality, were also analyzed. The relative risks of myocardial infarction (MI), death from cardiovascular (CV) causes, and stroke were significantly reduced (P=0.0001) by 20% (95% CI, 0.70-0.90), 26% (95% CI, 0.64-0.87), and 32% (95% CI: 0.56-0.84), respectively, in the ALTACE group as compared to the placebo group. The relative risk of death from any cause was also significantly reduced (P=0.005) by 16% (95% CI, 0.75-0.95) in the ALTACE group as compared to the placebo group. Notably, treatment with ALTACE was beneficial among patients who were already receiving a number of effective CV risk-reduction medications, including aspirin, beta-blockers, and lipid-lowering agents.

10 Atherosclerotic disease is a progressive disease as shown in this slide. Many therapeutic interventions are aimed at specific cardiovascular conditions. These interventions may be directed at alleviating symptoms or preventing progression to more serious stages or both. Angiotensin-converting enzyme (ACE) inhibitors have been studied, for example, in patients with hypertension, who are at the top of this progression pathway. These studies looked only at the effects on blood pressure, however, and did not address the long-term question of risk reduction. Other clinical trials with ACE inhibitors have been designed to investigate the effects of these agents on the morbidity and mortality following an acute myocardial infarction.

5.
ACC/AHA Classification <ul><li>Class I : Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. </li></ul><ul><li>Class II : Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. </li></ul><ul><li>Class IIa : Weight of evidence/opinion is in favor of usefulness/efficacy. </li></ul><ul><li>Class IIb : Usefulness/efficacy is less well established by evidence/opinion. </li></ul><ul><li>Class III : Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. </li></ul>1/00 medslides.com JACC 1999; Vol 33, No 7:2092-197

8.
History: chest discomfort <ul><li>Quality - &quot;squeezing,&quot; &quot;griplike,&quot; &quot;pressurelike,&quot; &quot;suffocating&quot; and &quot;heavy”; or a &quot;discomfort&quot; but not &quot;pain.&quot; Angina is almost never sharp or stabbing, and usually does not change with position or respiration. </li></ul><ul><li>Duration - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina </li></ul><ul><li>Location - usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely anginal. </li></ul><ul><li>Provocation - angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes. </li></ul>1/00 medslides.com

10.
Grading of Angina of Effort by the Canadian Cardiovascular Society <ul><li>I. “Ordinary physical activity does not cause … angina,” such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation. </li></ul><ul><li>II. “Slight limitation of ordinary activity.” Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. </li></ul><ul><li>III. “Marked limitation of ordinary physical activity.” Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace. </li></ul><ul><li>IV. “Inability to carry on any physical activity without discomfort -- anginal syndrome may be present at rest.” </li></ul>1/00 medslides.com Circulation 1976; 54:522-523

13.
History: Risk Factors for CAD <ul><li>Increases the likelihood that CAD will be present </li></ul><ul><ul><li>cigarette smoking </li></ul></ul><ul><ul><li>hyperlipidemia </li></ul></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>hypertension </li></ul></ul><ul><ul><li>family history of premature CAD </li></ul></ul><ul><ul><li>past history of CVA or PVD </li></ul></ul>1/00 medslides.com

14.
Estimate the probability of significant CAD Bayesian Analysis - &quot;Is it the heart?&quot; <ul><li>low probability of CAD ( 5% ) - the positive predictive value of an abnormal test result is only 21%. </li></ul><ul><li>intermediate probability of CAD ( 50% ), a positive test result increases the likelihood of disease to 83% and a negative test result decreases the likelihood to 36%. </li></ul><ul><li>high probability of CAD ( 90% ) - a positive test result raises the probability of disease to 98% and a negative test result lowers probability to 83%. </li></ul>1/00 medslides.com

16.
Probability Estimate the Duke and Stanford models <ul><li>age , gender and pain type were the most powerful predictors </li></ul><ul><li>other predictors </li></ul><ul><ul><li>smoking (defined as a history of smoking half a pack or more of cigarettes per day within five years of the study or at least 25 pack-years) </li></ul></ul><ul><ul><li>Q wave or ST-T-wave changes </li></ul></ul><ul><ul><li>hyperlipidemia (defined as a cholesterol level >250 mg/dL) </li></ul></ul><ul><ul><li>diabetes (glucose >140). Of these risk factors, diabetes had the greatest influence on increasing risk. </li></ul></ul>1/00 medslides.com Am J Med 1983;75:771-80 ; Am J Med 1990;89:7-14 Ann Intern Med 1993;118:81-90

24.
12 Lead Resting ECG <ul><li>should be recorded in all patients with symptoms suggestive of angina pectoris </li></ul><ul><li>normal in  50% of patients </li></ul><ul><li>a normal ECG does not exclude severe CAD; however, it does imply normal LV function with favorable prognosis </li></ul>1/00 medslides.com

25.
Risk Stratification: abnormal rest ECG <ul><li>Evidence of > 1 prior MI (Q waves or R wave in lead V 1 for posterior infarction) </li></ul><ul><li>A &quot;QRS score&quot; to indicate the extent of old or new MI </li></ul><ul><li>persistent ST-T wave inversions, particularly in leads V 1 to V 3 of the rest ECG, is associated with an increased likelihood of future acute coronary events and a poor prognosis </li></ul><ul><li>LV hypertrophy by ECG criteria in a patient with angina pectoris is also associated with increased morbidity and mortality </li></ul><ul><li>A decreased prognosis is also likely when the ECG shows left bundle-branch block, bifascicular block (often left anterior fascicular block plus right bundle-branch block), second- or third-degree atrioventricular block, atrial fibrillation or ventricular tachyarrhythmias </li></ul>1/00 medslides.com Am J Cardiol 1982;49:1604-14

27.
Four Key Questions <ul><li>Does the history suggest an intermediate to high probability of CAD? If not, history and appropriate diagnostic tests will usually focus on non-cardiac causes of chest pain. </li></ul><ul><li>Does the patient have intermediate- or high-risk unstable angina? </li></ul>1/00 medslides.com

28.
Four Key Questions <ul><li>Has the patient had a recent MI (<30 days) or has the patient recently (<6 months) undergone PCI or CABG? </li></ul><ul><li>Does the patient have comorbid condition such as severe anemia that may precipitate myocardial ischemia in the absence of significant anatomic coronary obstruction? </li></ul>1/00 medslides.com

34.
Risk Stratification for Death or MI <ul><li>“ Whenever possible, treadmill or bicycle exercise should be used as the most appropriate form of stress because it provides the most information concerning patient symptoms , cardiovascular function and hemodynamic response during usual forms of activity ” </li></ul>1/00 medslides.com

37.
Prognostic Markers in Exercise Testing The Duke Treadmill Score (risk calculation) <ul><li>The Duke treadmill score = </li></ul><ul><ul><li>exercise time in minutes on Bruce Protocol </li></ul></ul><ul><ul><li>minus 5x the ST-segment deviation (during or after exercise, in millimeters) </li></ul></ul><ul><ul><li>4x the angina index (“0” if there is no angina, “1” if angina occurs, and &quot;2&quot; if angina is the reason for stopping the test). </li></ul></ul><ul><li>works well for both inpatients and outpatients, and equally well for men and women </li></ul>1/00 medslides.com N Engl J Med 1991;325:849-53

40.
Stress Perfusion Studies for Risk Stratification <ul><li>Normal poststress thallium scan </li></ul><ul><li>highly predictive of a benign prognosis even in patients with known CAD </li></ul><ul><li>a rate of cardiac death and MI of 0.9% per year, nearly as low as that of the general population </li></ul><ul><li>In a recent prospective study of 5,183 consecutive patients, mean follow-up 642 ± 226 days, normal scans were at associated with low risk (<0.5% per year) for cardiac death and MI </li></ul><ul><li>the single exception would appear to be patients with high-risk treadmill scores and normal images </li></ul>1/00 medslides.com Circulation 1998;97:533-43

46.
Cost-effective Use of Noninvasive Tests <ul><li>When appropriately used, noninvasive tests are less costly than coronary angiography and have an acceptable predictive value for adverse events This is most true when the pretest probability of severe CAD is low </li></ul><ul><li>When the pretest probability of severe CAD is high, direct referral for coronary angiography without noninvasive testing has been shown to be most cost-effective as the total number of tests is reduced </li></ul>1/00 medslides.com Circulation 1995;91:54-65

47.
RISK STRATIFICATION Coronary Angiography and Left Ventriculography <ul><li>rationale is to identify high risk patients in whom coronary angiography and subsequent revascularization might improve survival </li></ul><ul><li>Such a strategy can be effective only if the patient's prognosis on medical therapy is sufficiently poor that it can be improved </li></ul>1/00 medslides.com

49.
Direct Referral For Diagnostic Coronary Angiography <ul><li>When Noninvasive Testing Is Contraindicated Or Unlikely To Be Adequate Due To Illness, Disability Or Physical Characteristics. For Example: </li></ul><ul><ul><li>coexisting chronic obstructive pulmonary disease </li></ul></ul><ul><ul><li>noninvasive testing is abnormal but not clearly diagnostic </li></ul></ul><ul><ul><li>patient's occupation or activity could constitute a risk to themselves or others </li></ul></ul><ul><ul><li>a high clinical probability of severe CAD </li></ul></ul><ul><ul><li>diabetics with paucity of symptoms of myocardial ischemia due to autonomic and sensory neuropathy </li></ul></ul>1/00 medslides.com

51.
Patients With Previous CABG <ul><li>progression of native CAD is not uncommon </li></ul><ul><li>development of obstructive atherosclerotic vein graft lesions are prone to rapid progression and thrombotic occlusion </li></ul><ul><li>low threshold for angiographic evaluation is recommended for patients who develop chronic stable angina >5 years after surgery, especially when ischemia is noninvasively documented in the distribution of a vein graft, the LAD is supplied by a vein graft, or multiple vein grafts are present </li></ul><ul><li>outcome can be improved by reoperation and by percutaneous catheter-based strategies </li></ul>1/00 medslides.com

52.
Exercise Testing in Patients With Chest Pain > 6 Months After Revascularization <ul><li>Recommendation Class IIb (Level of Evidence: B) </li></ul><ul><li>Rationale </li></ul><ul><ul><li>early phase to determine the immediate result of revascularization </li></ul></ul><ul><ul><li>Exercise testing also may be helpful in guiding a cardiac rehabilitation program and return-to-work decisions </li></ul></ul><ul><ul><li>late phase (  6 months) to assist in the evaluation and management of patients with chronic established CAD </li></ul></ul>1/00 medslides.com

59.
Antiplatelet Agents to Prevent MI and Death aspirin - Class I <ul><li>Aspirin 75 to 325 mg daily should be used routinely in all patients with acute and chronic ischemic heart disease with or without manifest symptoms in the absence of contraindications </li></ul><ul><ul><li>aspirin exerts an antithrombotic effect by inhibiting cyclo-oxygenase and synthesis of platelet thromboxane A 2 </li></ul></ul><ul><ul><li>in >3,000 patients with stable angina , aspirin reduced the risk of adverse cardiovascular events by 33% </li></ul></ul><ul><ul><li>in patients with unstable angina , aspirin decreases the short and long-term risk of fatal and nonfatal MI </li></ul></ul><ul><ul><li>in the Physicians' Health Study, aspirin (325 mg), given on alternate days to asymptomatic persons, was associated with a decreased incidence of MI </li></ul></ul>1/00 medslides.com BMJ 1995;308:81-106

60.
Antiplatelet Agents to Prevent MI and Death thienopyridine derivative - Class IIa <ul><li>thienopyridine derivative irreversibly inhibiting the binding of adenosine diphosphate (ADP) to its platelet receptors and thereby affecting ADP-dependent activation of the GP IIb-IIIa complex </li></ul><ul><li>Ticlopidine (Ticlid), unlike aspirin, has not been shown to decrease adverse cardiovascular events, but may induce neutropenia and thrombotic thrombocytopenic purpura (TTP) </li></ul><ul><li>Clopidogrel (Plavix), appears to possess a greater antithrombotic effect than ticlopidine. In patients with previous MI, stroke and peripheral vascular disease (i.e., at risk of ischemic events), clopidogrel appeared to be slightly more effective than aspirin in decreasing the combined risk of MI, vascular death or ischemic stroke (CAPRIE Trial) </li></ul>1/00 medslides.com Lancet 1996;348:1329-39

68.
BETA-BLOCKERS <ul><li>Mechanism of Action </li></ul><ul><ul><li>reduction in inotropic state and sinus rate </li></ul></ul><ul><ul><li>slowing of AV conduction </li></ul></ul><ul><ul><li>decreased myocardial oxygen demand, increased diastolic perfusion time </li></ul></ul><ul><li>Clinical Effectiveness </li></ul><ul><ul><li>improve the survival rate of patients with recent MI </li></ul></ul><ul><ul><li>improve the survival rate and prevent stroke and CHF in patients with hypertension </li></ul></ul><ul><ul><li>adjust the dose of  -blockers to reduce heart rate at rest to 55 to 60 bpm </li></ul></ul><ul><ul><li>increase in heart rate during exercise should not exceed 75% of the heart rate response associated with onset of ischemia </li></ul></ul>1/00 medslides.com

80.
Revascularization for Chronic Stable Angina PCI or CABG - Class I <ul><li>PCI for 2- or 3-vessel disease with significant proximal LAD stenosis, who have anatomy suitable for catheter-based therapy, normal LV function, and who do not have treated diabetes </li></ul><ul><li>PCI or CABG for 1-or two-vessel CAD without significant proximal LAD stenosis the with a large area of viable myocardium and high-risk criteria on noninvasive testing </li></ul>1/00 medslides.com

81.
Revascularization for Chronic Stable Angina PCI or CABG - Class I <ul><li>in patients with prior PCI, CABG or PCI for recurrent stenosis of social with with a large area of viable myocardium and/or high-risk criteria on noninvasive testing </li></ul><ul><li>PCI or CABG in patients who have not been successfully treated by medical therapy and can undergo revascularization was acceptable risk </li></ul>1/00 medslides.com

83.
5 Questions to Be Addressed in Follow-up of Patients With Chronic Stable Angina <ul><li>Has the patient decreased his or her level of physical activity since the last visit? </li></ul><ul><li>Have the patient's anginal symptoms increased in frequency and become more severe since the last visit? If the symptoms have worsened or the patient has decreased his or her physical activity to avoid precipitating angina, then he or she should be evaluated and treated appropriately according to either the unstable angina or chronic stable angina guideline. </li></ul><ul><li>How well is the patient tolerating therapy ? </li></ul><ul><li>How successful has the patient been in modifying risk factors and improving knowledge about ischemic heart disease? </li></ul><ul><li>Has the patient developed any new comorbid illnesses or has the severity or treatment of known comorbid illnesses worsened the patient's angina? </li></ul>1/00 medslides.com

84.
Follow-up: Frequency and Methods <ul><li>patient with successfully treated chronic stable angina should have a follow-up evaluation every 4 to 12 months </li></ul><ul><ul><li>during the first year of therapy - every four to six months </li></ul></ul><ul><ul><li>after the first year of therapy, annual evaluations if the patient is stable and reliable enough to call or make an appointment when anginal symptoms become worse or other symptoms occur </li></ul></ul><ul><li>patients who are co-managed by their primary-care physician and cardiologists may alternate these visits </li></ul><ul><li>annual office visits can be supplemented by telephone or other types of contacts </li></ul>1/00 medslides.com

85.
Focused Follow-up Visit: History <ul><li>General Status and New Concerns </li></ul><ul><ul><li>The open-ended question &quot;How are you doing?&quot; </li></ul></ul><ul><ul><li>A general assessment of the patient's functional status and quality of life </li></ul></ul><ul><li>Anginal Symptoms and Antianginal and Antiplatelet Therapy </li></ul><ul><ul><li>characteristics of the patient's angina </li></ul></ul><ul><ul><li>exacerbating and alleviating conditions </li></ul></ul><ul><ul><li>common drug side effects </li></ul></ul><ul><ul><li>patient's adherence to the treatment program </li></ul></ul><ul><li>Modifiable Risk Factors </li></ul><ul><li>Review of Existing Comorbid Illnesses That May Influence Chronic Stable Angina </li></ul>1/00 medslides.com

88.
Laboratory Examination on Follow-up Visits <ul><li>Laboratory Assessment for Noncardiac Conditions </li></ul><ul><ul><li>routine measurement of hemoglobin, thyroid function, serum electrolytes, renal function or oxygen saturation is not recommended </li></ul></ul><ul><ul><li>these tests should be obtained when required by the patient's history, physical examination or clinical course </li></ul></ul><ul><li>ECG and Follow-up Stress Testing </li></ul><ul><ul><li>there is no clear evidence showing that routine, periodic ECGs are useful in the absence of a change in history or physical examination </li></ul></ul><ul><ul><li>ECG can be repeated when medications affecting cardiac conduction are initiated or changed; change in the anginal pattern, symptoms or findings suggestive of a dysrhythmia or conduction abnormality and near or frank syncope </li></ul></ul>1/00 medslides.com

89.
Follow-up Stress Testing <ul><li>Despite widespread use of follow-up stress testing in patients with stable angina, there are very few published data establishing its utility </li></ul><ul><li>Risk stratify by formulating an estimate of the patient's cardiovascular risk over the next three years </li></ul><ul><ul><li>low-risk (estimated annual mortality < 1%) </li></ul></ul><ul><ul><li>intermediate-risk ( > 1% and < 3%) </li></ul></ul><ul><ul><li>high-risk (>3%) </li></ul></ul>1/00 medslides.com

90.
Follow-up Stress Testing low-risk patient <ul><li>In the absence of a change in clinical status, repeat stress testing are not required for 3 years after the initial evaluation </li></ul><ul><li>Examples of such patients are those with: </li></ul><ul><ul><li>low-risk Duke treadmill scores either without imaging or with negative imaging (four-year cardiovascular survival rate, 99%) - including patients with chest pain >6 months after coronary angioplasty who have undergone complete revascularization and do not have significant restenosis as demonstrated by angiography. </li></ul></ul><ul><ul><li>normal LV function and normal coronary angiograms </li></ul></ul><ul><ul><li>normal LV function and insignificant CAD </li></ul></ul>1/00 medslides.com

91.
Follow-up Stress Testing high- and intermediate- risk patient <ul><li>High-risk patients (>3%) </li></ul><ul><li>Annual follow-up testing might be useful in patients with: </li></ul><ul><ul><li>an ejection fraction <50% and significant CAD in > 1 major vessel </li></ul></ul><ul><ul><li>those with treated diabetes and multivessel CAD who have not undergone CABG </li></ul></ul><ul><ul><li>if the initial decision not to proceed with revascularization changes as the patient's estimated risk worsens </li></ul></ul><ul><li>Intermediate-risk ( > 1% and < 3%) </li></ul><ul><ul><li>problematic on the basis of the limited data available </li></ul></ul><ul><ul><li>may merit testing at an interval of one to three years, depending on their individual circumstances </li></ul></ul>1/00 medslides.com

93.
Principles of Patient Education <ul><li>A well-designed educational programs can improve patients' knowledge and in some instances has been shown to improve outcomes </li></ul><ul><ul><li>Assess the patient's baseline understanding </li></ul></ul><ul><ul><li>Elicit the patient's desire for information </li></ul></ul><ul><ul><li>Use epidemiologic and clinical evidence </li></ul></ul><ul><ul><li>Use ancillary personnel and professional when appropriate </li></ul></ul><ul><ul><li>Use professionally prepared resources </li></ul></ul><ul><ul><li>Develop a plan with the patient </li></ul></ul><ul><ul><li>Involve family members in educational efforts </li></ul></ul><ul><ul><li>Remind, repeat, and reinforce </li></ul></ul>1/00 medslides.com

95.
Patient-Specific Information <ul><li>PROGNOSIS </li></ul><ul><ul><li>useful to provide numerical estimates for risk of MI or death </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>informed about their medications, including mechanisms of action, method of administration, and potentially adverse effects </li></ul></ul><ul><li>PHYSICAL ACTIVITY </li></ul><ul><ul><li>reassurance about returning to normal activities, activity limitations, and sexual relations; potentially serious consequences of using both sildenafil and nitrates within 24 h of one another </li></ul></ul><ul><li>RISK FACTOR REDUCTION </li></ul><ul><ul><li>greatest emphasis should be placed on modifiable factors </li></ul></ul>1/00 medslides.com

96.
Patient-Specific Information <ul><li>CONTACTING THE MEDICAL SYSTEM </li></ul><ul><li>instructed about how and when to seek medical attention </li></ul><ul><li>provide an action plan that covers: 1) prompt use of aspirin and nitroglycerin if available 2) how to access emergency medical services 3) location of the nearest hospital that offers 24-h emergency cardiovascular care </li></ul><ul><li>OTHER INFORMATION </li></ul><ul><li>CPR training for family members is advisable </li></ul><ul><li>counseling on potentially heritable condition (such as familial hypercholesterolemia) responsible for premature coronary disease. </li></ul>1/00 medslides.com